General Tooth Gem Information

Tooth jewelry comes in the form of a lead-free gemstone and/or crystal. This jewelry is applied to the outside tooth surface and is semi-permanent (3 months-1 year+). The application process only takes a matter of minutes and is painless, provided the jewelry is applied to the surface of a healthy tooth. This is why it is very important to take proper consideration before moving forward. Your tooth jewelry provider is not a dental professional and therefore is only able to provide information regarding the service. It is up to you the client to consent and confirm if you are an eligible client for tooth jewelry to be placed. Please read over the consent form and highlight any questions or concerns to your tooth jewelry provider.

Medical history that would discourage tooth jewelry treatment

  • Epilepsy
  • Specific allergies (potentially nickel)

Dental history


requireddb save
Have you had tooth jewelry placed before?

requireddb save
Do you have sensitive teeth?

requireddb save
Do you have any orthodontic appliances currently on the front side of your teeth?

requireddb save
Do you wear retainers and/or other appliances? (nightguard/partial denture)

requireddb save
Have you had your teeth cleaned recently?

requireddb save
Do you have any chips/cracks and/or cavities along your smile line?

requireddb save
Do you have any fillings/crowns or veeners along your smile line?

requireddb save
Any photos/videos of my teeth are okay to be shared for media purposes

Retention

ALL tooth jewelry retention rates vary. There are a large amount of contributing factors that play into why tooth jewelry may fall off; bite force and chewy/sticky foods are just a few to mention. BW Beauty will honour one month of free replacement if needed.

Removal must be done by a dental office

If tooth jewelry comes off at home;

  • May fall off “clean” meaning no adhesive residue. This would not require a dentist visit as there would be no residue to remove.
  • May fall off “partially” meaning part of and/or full jewelry is missing but you can still feel adhesive on your tooth with your tongue. This would require a dental visit.

**Removal fees at a dental clinic are not part of application fees at BW Beauty and are to be paid by the client.

Things to note

  • Your tooth structure around the tooth jewelry maybe rough for 24-48 hours
  • Gum/tooth irritation may be present
  • If you get material on lips/hands or anywhere outside of the oral cavity during the service there maybe some stinging and white spots will occur. If on lips for a long period of time it will blister

Client

I have read the information provided and understand the possible risks/limitations to a tooth jewelry procedure. The staff answered any further questions I have and I consent to this treatment and understand that ALL RETENTION RESULTS VARY


Emailrequired
Phone (Digits Only)required
First Namerequired
Last Namerequired

Date: 22.04.2024

Time: 11:40 AM

Client Signaturerequired
Tap to Sign

Date: 22.04.2024

Time: 11:40 AM

Tooth Jewelry Technician Signatureoptional
Tap to Sign

I would like to get a copy of this document. I confirm my email address is spelled correctly.
I agree to Waiver Master Terms & Conditions and Privacy Policy available at waivermaster.com/terms.html and waivermaster.com/privacy.html.

By clicking/tapping/touching/selecting or otherwise interacting with the "Submit" button below, you are consenting to signing this Document electronically. You agree your electronic signature ("E-Signature") is the legal equivalent of your manual signature on this Document. You consent to be legally bound by this Document's agreement(s), acknowledgement(s), policy(ies), disclosure(s), consent term(s) and condition(s). You consent to be legally bound by Waiver Master's policies, terms and conditions available at waivermaster.com/terms.html and waivermaster.com/privacy.html . You agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You may request a paper version of an electronic record by writing to us. We reserve the right to charge a reasonable fee for the production and mailing of a paper version of the record. Your current valid email is required for all communications.




Submission Sequence: 2024-04-24T01:30:46.250Z9
DUUID Sequence: VZMNU9BDU9P_7f9bafe9-e969-4f42-aadc-8137c2cf665c
IP(s): 70.64.25.250, 18.68.41.46
CFID: cqJM0fFx9HPH4pxLlvzS5WJMh1fiCh1mpG8mcPiXakSp0R98lxgfcA==
TRACEID: Root=1-662860c6-556f42c2533eaf165e6450d7
UA: Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) SamsungBrowser/24.0 Chrome/117.0.0.0 Mobile Safari/537.36